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The loss of a pregnancy or miscarriage is something that most couples rather not think of. However, it’s important for couples to understand why miscarriages can happen, especially as it can be caused by various factors and steps can be taken to lower the risks. The common causes of miscarriage are anatomical causes (like uterine abnormality), genetic causes, immunological disorders and hormonal imbalance. In this article, I will address one of the most common types of hormonal imbalance known today – insulin resistance.

Insulin resistance is a condition whereby levels of sugar, estrogen and testosterone in the blood are raised, while progesterone levels are lowered. The result is an excess of glucose in the bloodstream, which leads to prediabetes, diabetes and other serious health disorders. In pregnancy, insulin resistance causes a variety of concerns, such as delayed fetal growth and gestational diabetes.

Several scientific studies have also found that insulin resistance can lead to miscarriage. One such study was carried out by a team of researchers at the Reproductive Medical Centre, Peking University, People’s Hospital, Beijing, China. After examining 107 patients that achieved their first pregnancy after infertility treatment, they came to the conclusion the risk of miscarriage can be directly linked to insulin resistance.

A team from the Obstruction & Gynecology Department, Babol University of Medical Science, Babol, Iran offered similar findings, when they proved that women with elevated insulin levels are at a higher miscarriage risk. As worrying as this is, it must be noted that insulin resistance doesn’t just heighten the risk of miscarriage; in fact, it has been shown to increase the risk of multiple miscarriages.

Several published studies have confirmed this, such as one by a team from the Department of Obstetrics and Gynecology at Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou. After investigating the differences in insulin resistance between women with recurrent miscarriage and those with normal pregnancy, they concluded that insulin resistance increases the risk for recurrent miscarriage during the first trimester of pregnancy.

The crucial link between insulin resistance and recurrent miscarriage was echoed in a prospective clinical study by a team of researchers from the Department of OB & GYN, Shiraz Medical University, Iran. Their study found that 39% of women with recurrent miscarriage have abnormal oral glucose tolerance test (OGTT) results. The OCTT, which measures the body’s ability to use glucose, is often used to check for insulin resistance and gestational diabetes.

Meanwhile, a team from the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, USA concluded that 27% of women with repeat miscarriage have high fasting insulin, despite normal glucose levels.

Insulin resistance is also associated with Polycystic Ovarian Syndrome or PCOS, which is why women with PCOS struggle with infertility. The condition raises levels of estrogen and testosterone in the body, while lowering progesterone levels. This interferes with the normal development of follicles in the ovaries, causing problems with ovulation.

However, if you have PCOS or insulin resistance and wish to undergo infertility treatment, hope is not lost. There are steps you can take to improve your insulin resistance sensitivity through lifestyle changes or medical intervention, before you undergo infertility treatment. Please don’t hesitate to speak to your infertility consultant should you have any concerns about insulin resistance. Your doctor can advise you on ways to reduce your risks and increase your chances for a safe pregnancy.

A miscarriage is a devastating experience for couples, perhaps even more so for those who have struggled with infertility and gone through the initial joy of a successful fertility treatment. Statistics have shown that in both natural and IVF conception, about one in six pregnancies will end in a miscarriage before the 20th week, with the rate being higher in older couples.

Understandably, couples are frightened of miscarriages and would rather not think or talk about it. However, it is important for couples to understand why miscarriages happen, as well as what they can do to reduce their risks.

Although the exact reason for a miscarriage is often unexplainable, it can occur due to a number of reasons. These include chromosomal abnormality, improper implantation of the egg and maternal health problems or trauma. The mother’s age also plays a significant role, as does her lifestyle, which includes exposure to stress, smoking, drug use, malnutrition, excessive caffeine, radiation and toxins.

Another well-studied factor than increases a woman’s risk for miscarriage, is her weight. As these studies indicate, if the mother is obese or underweight, this increases her risk of not only infertility, but miscarriage as well, regardless of the method of conception.

According to researchers at the Department of Obstetrics and Gynaecology, University of Adelaide, Australia, being overweight increase a woman’s risk of miscarriage by 29%, while being obese can increase the risk by 71% or more. However, for women undergoing assisted reproduction, researchers at the Assisted Fertilization Center, Brazil concluded that maternal obesity could increase the risk of miscarriage by up to 1330%.

Obesity also compounds miscarriage rates in women with PCOS. The Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey found that the miscarriage rate in obese women with PCOS is about nine times higher than average.

And while miscarriage is often the result of an unhealthy fetus, researchers from the Department of Obstetrics and Gynecology, Stanford Hospital and Clinics, CA, USA found that the risk of miscarriage of a healthy fetus is significantly higher in obese women (with BMIs of 25 or more).

While obesity has been identified as a risk factor for spontaneous miscarriage, the mechanism for it remains unclear. But a study by The Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield and Sheffield Teaching Hospitals, Sheffield, UK points to the endocrinological changes in obesity as possibily causing complex adverse effects including circulating adipokines, sex steroids and insulin resistance.

Women who are underweight, with a BMI of under 20, also face an increased miscarriage risk. A study by researchers at the German Cancer Research Centre found that pregnant women who were underweight faced a 70 % higher risk of having a miscarriage.

Therefore, it can be concluded that among intrauterine environmental factors, nutrition appears to play the most critical role in influencing placental and fetal growth. Since maternal undernutrition or overnutrition during pregnancy can impair fetal growth, women must adopt healthier diets and incorporate exercise to lower their risk of miscarriage.

If you have any concerns regarding miscarriage, especially after IVF, please do not hesitate to consult with your fertility consultant for advice.

If you and your partner have been struggling with fertility issues and are seriously considering In-Vitro Fertilisation or IVF, the consideration of whether you should be undergoing PGD and PGS on top of an IVF can be quite daunting. This is because, in normal IVF procedures, the best embryos are selected based on their appearance and morphology only. Therefore, the genetic content of those embryos or any chromosomal abnormality cannot be detected. However, by undergoing PGD and PGS, you will be able to screen your embryos for any potential genetic and chromosomal issues. However, before we jump into the band wagon of having PGS or PGD, there are a few things we need to consider.

What is PGS?
PGS stands for Pre-implantation Genetic Screening. In PGS, a cell is taken from an embryo which was created following an IVF procedure, so that it can be tested for chromosomal abnormalities before the embryo is transferred to the womb. This test will be able to tell us whether the embryo has normal sets of chromosomes. However, it will not be able to tell us whether this embryo has a genetic problem or not.

It is important to note that not all the patients going through an IVF required a PGS. You may want to consider it if:

You are of advanced maternal age, whereby embryos may show greater levels of chromosomal abnormalities.

You have had recurrent miscarriages.

You have had repeated IVF failure.

Either of you has a chromosome rearrangement.

The PGS procedure involves:
1. You will undergo a normal IVF treatment and your eggs will be collected and fertilised.
2. An embryo is grown in the laboratory for a few days.
3. An embryologist will perform a biopsy and remove a few cells, usually on day 3 or 5.
4. All 24 chromosomes are analysed (22 non-sex chromosomes and two sex chromosomes X & Y).
5. If the embryo is normal, it will be transferred into your womb.
6. Any remaining unaffected embryos can be frozen for later use.
7. Affected embryos will be allowed to perish.

What is PGD?
PGD is an abbreviation for Preimplantation Genetic Diagnosis. In PGD, a cell is taken from an IVF embryo so that it can be tested for a specific genetic condition before the embryo is transferred to the womb. It can be used to test for any genetic condition that is known to be caused by a specific gene.

At present, PGD is used to screen for more than 250 genetic conditions, such as Huntington’s disease, Cystic fibrosis, Thalassaemia, Duchenne muscular dystrophy and Fragile-XPDG to name but a few. Therefore, PGD enables individuals with an inheritable genetic condition to avoid passing it on to their children. The PGD process is more tidious and challenging compared to PGS. It is used to test for a specific genetic disease which is known to your family, i.e. you or your partner is confirmed a carrier of a specific gene at a certain point of the chromosome. You need to bear in mind that by performing a PGD, it does not mean that screening of ALL genetic diseases are performed at the same time. This is because human beings have millions of gene and it is impossible to screen ALL of the genes in one go.

However, not all IVF patients need to undergo PGD. You may want to consider it, or your specialist may recommend it to you if:

• You or your partner (or both) are carriers of single gene mutations.
• You ended a previous pregnancy due to a serious genetic condition.
• You have a child with a serious genetic condition.
• Either of you has a family history of a serious genetic condition or chromosome problems.

The PGD procedure involves

1. You will undergo a normal IVF treatment and your eggs will be collected and fertilised.
2. An embryo is grown in the laboratory for a few days, until it has divided into around 8 cells.
3. An embryologist will remove one or two of the cells from the embryo.
4. The cells are tested to see if the embryo has a gene that causes a genetic condition.
5. If the embryo is free of any genetic condition, it is transferred to the womb.
6. Any remaining unaffected embryos can be frozen for later use.
7. Affected embryos will be allowed to perish.

Since PGD and PGS help detect genetic conditions and chromosomal abnormalities, they help IVF patients to decide if they wish to continue with pregnancy.

The Pros and Cons of PGD and PGS
Before you decide on undergoing PGD or PGS, your fertility consultant will explain their pros and cons to you, which include:

Pros

They can detect an inherited chromosomal or genetic issues and help prevent passing chromosomal or genetic diseases to the next generations

They are a form of early detection of chromosomal or genetic problems before the embryo is transferred back into the uterus.

They help increase a couple’s chances of conceiving a healthy child.

It allows older women to still have viable children.

Cons

There is a risk that embryos may be traumatized or destroyed due to damage during the biopsy process.

There is always a possibility of an undetected disease, as no form of testing can guarantee 100% accuracy

The test is expensive

You may not have any embryos to transfer after the IVF & PGD/PGS , which is frustrating for patients because after investing time, money & effort, the result can be disappointing

There is no guarantee that an embryo which had been screened will definitely get implanted after being transferred into the uterus. Therefore, there is no guarantee that a PGS/PGD embryo will give you a life birth.

If you and your partner are interested in or have any concerns about PGD and PGS, be sure to speak to your fertility specialist to address concerns, inquiries and options.